Chronic Pain: The Silent Epidemic – and the Insights That Offer Hope

(The article was edited by Dr. Yaakov Fogelman – a pain management physician)

introduction

“Doctor, I feel sick!” – is perhaps the most common complaint heard in general practice. Pain, as defined by the International Society for the Study of Pain, is An unpleasant feeling and emotional experience, associated with actual or potential tissue damage, or described in such terms.

Beyond the need to treat the pain itself and its causes, pain is a significant factor in impairing function and quality of life, and in cases of chronic pain - also in mood and mental health.

First (true) story:

About 30 years ago, following a car accident, I suffered from severe back pain. I was sent for X-rays, and I appeared before a neurosurgeon. The doctor looked at the photos, looked at me, and looked at the photos again.

Finally, the doctor said an unforgettable sentence to me: "Judging by the photos alone, I'm not sure how you even managed to get here, and where you are in the operating room. But if you did, it probably isn't that bad." He sent me home, and somehow things worked out.

Second (true) story:

A friend I know fell and suffered from knee pain. He arrived at the emergency room, had an X-ray, and went to see an orthopedist. The orthopedist looked at the X-ray and said, "Well, the cartilage is worn away, bone on bone, what do you want?" He hinted that the only way out was knee replacement surgery.

These two cases represent common events that a significant portion of readers will encounter at one point or another in their lives (recommended as late as possible).

The dilemma of what to do when "I'm in pain," and what we can expect the doctor to do for us, is more relevant than ever. Recently, at a meeting of the 53rd class of the Reali School, we were privileged to hear a fascinating lecture by Dr. Yaakov Fogelman - a graduate of the class and a doctor in the field of pain. I was impressed by the content and insights, and decided to share the main points of his remarks here.

Dr. Fogelman comments on the two stories above:

We know from research and clinical experience that there may be a gap between serious radiological findings (such as "bone on bone" or "herniated discs") and the actual sensation of pain. That is, there are people with severe degenerative changes on radiographs who experience no pain at all or only mild pain.

Various studies in the field of orthopedics show that there is a discrepancy between imaging findings (such as X-rays, MRIs, etc.) and the intensity of symptoms: for example, approximately 15% to 76% of subjects with significant degenerative findings (in the knee, for example) do not report any pain at all. It can be assumed that a similar rate also exists in the hip joint, but there is no specific data regarding "bone on bone" in the hip and no pain.

In conclusion: It is not possible to specify an exact number, but there are quite a few patients with "bone on bone" on an X-ray of the hip who do not experience pain. The same goes for lower back pain with "herniated discs." The gap between imaging and clinical symptoms is well known in pain medicine and orthopedic medicine.

Acute pain and chronic pain

Acute pain is characterized by a short-term and limited effect.

Examples of acute pain: toothache, injury, menstruation, migraine. Acute pain causes restlessness and anxiety, but it gradually decreases and disappears. In addition to treating the source of the problem, acute pain is treated with medications that sometimes do not require a prescription.

Chronic pain is pain that persists for a long time (over 6 months).

Examples: back and knee pain. Or pain from another chronic illness. Chronic pain may lead to avoidance of activity, social isolation, sleep problems, and depression. Usually, the intervention of a physician for drug treatment and other professionals for comprehensive treatment is required.

Chronic pain – the pain that doesn't let up

Chronic pain has long been familiar to many of us. The older we get, the more familiar we become with it – back, knees, joints. This phenomenon bothers about 20% of the world's population. In Israel, nearly two million people suffer from it.

Dr. Fogelman, a former family physician, quickly discovered that many of his referrals were for acute or persistent pain. In the 1980s, the arsenal of treatment tools was limited. Sometimes, rest and a few anti-inflammatory pills were all that could be offered.

But then imaging devices arrived – CT and MRI – and changed the face of medicine.

The Mechanical Revolution – and what we discovered after it

The paradigm that was established with the introduction of imaging was simple: "Is there pain? It must have a physical cause that is visible in the photograph."

Doctors began to identify various findings – herniated discs, cartilage erosion, tears – and began to treat accordingly. Invasive treatments such as knee lavage became common. But the reality was more complex. In 2013, a surprising study was published in the prestigious journal "New England Journal of Medicine". The study showed that the knee lavage procedure was no more effective than a sham operation. Similar results were obtained in other studies, placing a big question mark on the "what you see is what hurts" approach.

Other studies have yielded even more surprising results. With the exception of one category of "classic surgeries," in all cases sham surgeries (the placebo effect) resulted in much greater improvement than actual surgeries!

And when looking at the improvement in pain perception, the results were nothing short of amazing – 78% of the improvement was measured in the sham surgery group!

Pain – not just a matter of the body

Another important breakthrough in understanding pain was made possible by another study from 2013, published in the journal Brain, which relied on advanced brain imaging (fMRI). The study found that acute pain activates certain areas of the brain, while chronic pain activates other areas, such as those related to emotion and memory.

That is, pain is not only the result of physical damage, but also of mental interpretation, emotional state, and even life circumstances.

How did the brain evolve?

A few words about the process by which the brain evolved.

• The first brain system to evolve in living creatures (about 300 million years ago) is Brain stem. Its role was the maintenance and functioning of the body's basic and autonomic systems.
• After it (200-250 million years) came The limbic systemThis system is identified with emotion and its function is to fulfill survival needs – eating, reproducing,…
• The cortex  (150 million years ago) already engaged in higher and more complex actions – perception, planning, thinking, language…

Studies show that pain begins its journey in the limbic system and from there to the brainstem. The limbic system considers what to do with it, and at a certain point decides to "bother" the cortex with pain.

Thus, in extreme cases (for example, a battle injury), the limbic system inhibits the transmission of pain to the cortex, to enable the victim's survival activity.

When the limbic system – our emotional system – is in a low-functioning state of anxiety, depression, and insecurity, it will flood the cortex with uncontrolled pain stimuli, thus directly affecting the experience and intensity of pain.

When we are in a poor mental state, the pain may worsen. When we function better mentally, the pain also tends to subside and the rehabilitation time is shortened.

Pain is a disease – not just a symptom

Today, the current medical concept regards chronic pain as an independent disease, which must be treated comprehensively – physically, emotionally, and functionally. To do this, the doctor must understand the full picture.

He will do this by asking the patient the following questions:

• What event started the pain?
• What intensifies the pain and what relieves it?
• What is the quality of the pain (sharp pain, stabbing, aching, etc.)
• Is there any radiating pain in other places, does the pain limit movement?
• The intensity of the pain
• Timing – When does the pain appear?

After this investigation, the doctor will perform a thorough physical examination, which usually includes:

• Extreme review
• Range of motion
• Tissue structure, sensitivity test
• Neurological examination (numbness, reflexes, etc.)

In the vast majority of cases, the doctor will reach a good diagnosis at the end of this process. In cases where the doctor has doubts, suspicions, or a desire to find out more, he will send the patient for imaging.

What do we do with all the pathological findings?

It turns out that many of the findings that appear on imaging scans are also present in people who do not complain of pain. For example:

• In the lower back: 52% have cartilage degeneration by age 30, and 96% by age 80
• In the neck: 87% of the population has a herniated disc
• In the shoulder: 72% have tears in the upper labrum (cartilage)
• In the hip joint: 69% of adults have labrum (cartilage) tears
• In the knee: 97% have "pathological findings"
• Ankle and foot: 63% have changes in the Achilles tendon

So does everyone need surgery? Of course not.

Pain, Muscle – and Western Acupuncture

Fascia is the tissue that surrounds the muscle. Pain can come from the muscle, but when the fascia tissue is diseased, the pain comes from the abnormal interaction between the muscle and the fascia that surrounds it.

In 1938, a Jewish doctor named Jonas Kellgren made an interesting discovery. He discovered that a contracted and injured muscle radiates pain to specific areas, which can be far from its anatomical location. Through experiments with injections of saline solution (6%) into the muscles of the body, the understanding developed that each muscle in the body has its own pain projection.

Clinicians such as Janet Travel, President Kennedy's personal physician, and David Simmons, mapped the connections between different muscles and characteristic pain radia- tions.

Following their efforts and the efforts of other researchers, we now have an accurate mapping of the pain projections of all the muscles of the body.

Thus, a tight chest muscle, for example, can trigger a pain response that is characteristic of a myocardial infarction. Over time, it became clear that stabbing the muscle in a certain place releases it, and with it the pain disappears.

This breakthrough later brought with it the Western acupuncture method (Dry Needling), which quickly reduces pain by releasing "tight" muscles with the help of a fine needle.

Today, a large number of family doctors and other therapists have undergone training in this treatment (which is convenient to administer and takes a short time in its treatment room), and some are even practicing therapists.

From hospital pain clinics to community medicine

Dr. Fogelman says: "In 2001, I participated in a training course for general practitioners held at Dr. Wolfson's pain clinic at Rambam. Dr. Wolfson pointed out a serious systemic problem: about 20% of the population suffers from chronic pain.

There are nearly 2 million people in Israel. The existing pain clinics are prepared to treat with great effort no more than 30,000 per year - less than 2% of the population. What will the other 98% do?

The solution proposed by Dr. Wolfson was to train general practitioners in pain management. In this way, he essentially marked the breakthrough of pain medicine outside the walls of hospitals into general medicine. Patients began to receive appropriate treatment in the community environment and did not have to wait long months for treatment in hospital pain clinics.

Summary

Pain treatment has undergone a real revolution: from being based on imaging and analysis – to a deeper understanding of the subjective experience, the influence of mental state, and the central role of the brain and emotion. Chronic pain is a common, painful and complex phenomenon – but with the right diagnosis and a holistic approach, it is possible to help, relieve, and in rare cases – even cure.